Nokea
The nurse is preparing a staff in-service regarding conductive hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
- A. Presbycusis
- B. Prolonged exposure to noise
- C. Foreign body
- D. Ototoxic substance
- E. Cerumen
Correct Answer: C,E
Rationale: Foreign bodies and cerumen obstruct the ear canal, causing conductive hearing loss.
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A 30-year-old man was involved in a head-on collision and was unconscious for two minutes prior to EMS arrival. Five minutes before arriving at the hospital, the paramedic notices clear fluid draining from the patient's nose. Having seen this before, the paramedic places a drop from the patient's nose onto a piece of gauze. The nurse is looking for a clinical finding that is called the halo's sign. What type of fracture does the paramedic suspect the patient has?
- A. Depressed skull fracture
- B. Traumatic linear skull fracture
- C. Subarachnoid hemorrhage
- D. Basilar skull fracture
Correct Answer: D
Rationale: Halo sign (clear fluid with a yellow ring on gauze) suggests cerebrospinal fluid leak, commonly associated with basilar skull fracture.
The nurse is caring for a client who was prescribed lamotrigine. The nurse understands that this medication is intended to treat
- A. Acute spinal shock
- B. Epilepsy
- C. Parkinson's disease
- D. Multiple sclerosis
Correct Answer: B
Rationale: Lamotrigine is an anticonvulsant primarily used to treat epilepsy. It is not indicated for spinal shock, Parkinson's disease, or multiple sclerosis.
The following scenario applies to the next 1 items
The outpatient clinic nurse cares for a 40-year-old female client.
Item 1 of 1
Nurses' Notes
1450: Client reports to the clinic with her daughter because of various concerning symptoms that started about eight months ago. The client's daughter has noticed that her mother has become increasingly clumsy and uncoordinated. She reports that she is tripping over her own feet, which has caused her to fall twice. The client's daughter also reports becoming emotionally labile for 'no apparent reason.' The client reports that she gets 'spells of double vision that lasts for a few days' that seem to worsen with the heat. The client's daughter is concerned because her mother is not the 'get up and go' type of woman she used to be. The client does endorse generalized fatigue that worsens as the day progresses. In fact, she states
She goes to bed early because she gets so tired by 6 pm. The client says that two weeks ago, her vision doubled so much that she purchased an eye patch at the drugstore, which did help. Her daughter reports checking on her mother; her language was garbled and unrecognizable. She was almost ready to take her to the ED because she thought she was having a stroke. Finally, the client provided documentation from two urgent care visits in the past six months because of urinary tract infections. The client indicates she has had urinary problems dealing with urgency. She states that she has no pain, and in fact, she has difficulty determining if she has a UTI because she has decreased sensation in her pelvic region, which she cannot explain. On assessment, the client's breathing is unlabored, and breath sounds are clear bilaterally. Skin warm to touch with no tenting; bruising noted on the client's shins; pulses 2+ and regular. Capillary refill is 3 seconds. The client is alert and oriented to person, place, and situation. She currently takes no medications and has a medical history of uterine fibroids.
For each client finding below, click to specify if the finding is consistent with the disease process of Parkinson's disease, myasthenia gravis, or multiple sclerosis:
- A. Diplopia
- B. Emotional lability
- C. generalized fatigue
- D. Muscle incoordination
- E. diminished response to pain
- F. heat sensitivity
- G. urinary urgency
Correct Answer: B,C,A,C
Rationale: Diplopia is common in myasthenia gravis (due to ocular muscle weakness) and multiple sclerosis (due to optic nerve involvement). Emotional lability is a hallmark of multiple sclerosis due to demyelination affecting emotional regulation. Fatigue is common in myasthenia gravis (muscle fatigability) and multiple sclerosis (due to neurological dysfunction).
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 4 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
For each potential nursing intervention, click to specify whether the intervention is indicated or not indicated for the care of the client: A= Indicated, B= Not Indicated
- A. Keep the door to the client's room closed to maintain negative airflow
- B. Provide visitors with face shields upon entering the client's room
- C. Provide a quiet environment
- D. Perform frequent neurological assessments
- E. Obtain an order to start a peripheral vascular access device
- F. Prepare the client for an immediate electroencephalography (EEG)
Correct Answer: B,B,A,A,A,B
Rationale: Negative airflow is not typically required for bacterial meningitis unless airborne precautions are specified. Face shields are not standard for meningitis; droplet precautions are usually sufficient. A quiet environment reduces stimulation for a client with neurological symptoms. Frequent neurological assessments are critical for monitoring meningitis progression. IV access is necessary for administering antibiotics and fluids in suspected meningitis. EEG is not indicated unless seizures are suspected.
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect?
- A. Unilateral frontotemporal pain
- B. Nausea
- C. Photophobia
- D. Fever
- E. Nuchal rigidity
- F. Vomiting
Correct Answer: A,B,C,F
Rationale: Migraine headaches typically present with unilateral pain, nausea, photophobia, and vomiting.